When it comes to social networking websites, advocates say hospitals can have it both ways—reaping the benefits of their participation and avoiding any HIPAA privacy violations.
We went to medical school. We studied, and many of us learned about pathogenesis of diseases. We were encouraged by our attendings and throttled by our chief residents to be able to spout off the causes of conditions. It wasn’t enough to name the condition; we had to know the myriad possible etiologies. Being quizzed made us sharp. We started to learn patterns and became better diagnosticians because we could digest the complexities of a patient while we did the history and physical. And we knew, even before lab tests came back, what was going on with the patient and how it got there.
Present-on-admission (POA) indicators, hospital-acquired conditions (HAC), and never events have been around for a while. However, they still seem to cause compliance conundrums, says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA.
It should come as no surprise that medical record documentation made the list for top standards noncompliance for the first half of 2010. Our old favorites just won’t go away.
MRB recently asked several advisory board members for crucial tips that new HIM managers and directors should know as they learn their way around their job and department.
